Provider Demographics
NPI:1376639955
Name:FACTORA, TYRONE (OT)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:FACTORA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2536 INDUSTRIAL DR
Mailing Address - Street 2:STE 11
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404
Mailing Address - Country:US
Mailing Address - Phone:812-332-7529
Mailing Address - Fax:812-339-7529
Practice Address - Street 1:2536 INDUSTRIAL DR
Practice Address - Street 2:STE 11
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404
Practice Address - Country:US
Practice Address - Phone:812-332-7529
Practice Address - Fax:812-339-7529
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003809A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist